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Introduction: Compensatory inferior turbinate hypertrophy is a common accompanying manifestation in patients with nasal obstruction due to deviated nasal septum (DNS). The grounds for inferior turbinate reduction (ITR) in this population are still not well established. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of septoplasty with ITR versus septoplasty alone. Methods: Computerised search in Medline, Embase, and CENTRAL was performed. Eligible for inclusion were randomised controlled trials (RCTs) comparing septoplasty to septoplasty with unilateral, contralateral, ITR in adults with DNS. Primary outcomes were health-related quality of life and nasal patency. The secondary outcome was the occurrence of adverse events. Standardised mean differences (SMD) and odds ratios (OR) with 95% confidence intervals were calculated. Results: Twelve RCTs that enrolled 775 participants were found eligible. Data were reported at follow-up periods ranging from 1 month to 48 months. The pooled effect estimate showed a statistically significant improvement with unilateral, contralateral, ITR in Nasal Obstruction Symptom Evaluation scale (NOSE) scores. The rate of adverse events was significantly higher with ITR. Conclusions: Unilateral reduction of the hypertrophied contralateral inferior turbinate during septoplasty resulted in better subjective relief of nasal obstruction in adults with DNS than septoplasty alone. However, caution is warranted since only few well-designed RCTs were identified.

Background No adequate test exists to predict outcome after septoplasty. Despite adequate surgery, patients still might experience nasal breathing impairment. The aim of this study was to determine if pre-operative trigeminal sensitivity can predict satisfaction after septoplasty. Methods Single centre prospective cohort study in tertiary referral centre with follow-up time of 6 weeks postoperatively. Patients scheduled for septoplasty or septorhinoplasty with turbinoplasty were consecutively selected the day before surgery. Standard preoperative examinations (acoustic rhinometry and Sniffin’ Sticks 12 test), the evaluation of nasal obstruction on a visual analogue scale (VAS) and the trigeminal lateralisation task were performed before and 6 weeks after surgery. Biopsies were taken during surgery and TRPV1 mRNA expression was measured by PCR. Results Thirty patients were included with a median age of 29 years and equal gender distribution. Trigeminal perception and sensation of nasal obstruction showed a significant correlation: preoperative lateralisation test scores, representing endonasal trigeminal sensitivity, correlated significantly with the mean VAS change scores, which demonstrate subjective improvement. A lateralisation test score of 31.5 and more had a sensitivity of 88% to predict an improvement of more than 3 VAS points. Additionally, high TRPV1 mRNA expression was linked with good postoperative VAS scores. Conclusion The preoperative evaluation of the trigeminal sensitivity could improve patients’ selection for septoplasty with a higher rate of satisfaction. Endonasal trigeminal sensitivity is directly linked with subjective outcome. Therefore, patients with low trigeminal sensitivity should undergo septoplasty only after thorough counselling.

Background Sleep-related breathing disorders (SRBD) are common reported disorders in the adult population. The nose plays an important role in the development of SRBD; thus, the measurement of nasal respiratory function remains an important step in the management of these patients. Peak nasal inspiratory flow (PNIF) is a useful tool to assess nasal airflow and it has recently been studied together with peak oral inspiratory flow (POIF). Objective The aim of the present study was to evaluate the role of PNIF and POIF in an adult population of patients affected by SRBD. Methodology Seventy consecutive adult patients with SRBD were included in the present study. All patients were evaluated with home-based sleep studies (type III), PNIF, POIF, SNOT-22 questionnaire, Epworth Sleepiness Scale test and VAS for nasal obstruction. Results Although PNIF and POIF showed to correlate with each other, no correlations were observed between Apnea Hypopnea index (AHI) and PNIF, POIF or NPI (PNIF/POIF). A further analysis showed a marginal correlation between SNOT- 22 and AHI and between SNOT-22 and POIF. Furthermore, in a multivariate analysis, also POIF marginally correlated with some of the sleep- related SNOT-22 items. Conclusions In the present study neither PNIF nor POIF were found to be associated with OSAS severity. However, POIF values correlated better than PNIF with sleep related symptoms suggesting that POIF could be a more useful parameter for upper airway assessment in patients with SRBD. In addition, a correlation between OSAS severity, in terms of AHI, and SNOT-22 total score has been reported.

BACKGROUND The aim of this study was to investigate using computational fluid dynamics (CFD) the effects on nasal aerodynamics of two different techniques for reducing the inferior turbinate. This may assist in surgical planning to select the optimal procedure. METHODS Virtual surgery using two techniques of turbinate reduction was performed in eight nasal airway obstruction patients. Three bilateral nasal airway models for each patient were compared: 1) Pre-operative 2) Bilateral inferior turbinoplasty 3) Bilateral total inferior turbinate resection (ITR). Two representative healthy models were included. CFD modeling of airflow was performed under steady-state, laminar, inspiratory conditions. RESULTS Nasal airway resistance was slightly more reduced following ITR compared to turbinoplasty due to loss of the pressure gradient at the head of the IT. Turbinoplasty resulted in ventilation, pressure and wall shear stress profiles closer to those of healthy models. A more prominent jet-like course of the main flow stream was observed inferiorly in the ITR group. CONCLUSIONS Nasal air conditioning was significantly altered following IT surgery. Overall differences between the groups were small and are unlikely to bear influence on nasal function in normal environments. Further studies using a larger number of patients and healthy subjects are required, attempting to establish a clinical correlation with long-term outcomes such as the perception of nasal patency, mucosal crusting and drying, and air conditioning in different environments. Since a large proportion of IT mucosa remains following turbinoplasty, future dependence on topical therapy should also be considered.

Background Empty nose syndrome (ENS) is a debilitating disorder characterised by paradoxical nasal obstruction after excessive surgical excision of nasal tissues. ENS negatively impacts the quality of life (QOL) and psychological status of patients. This study aimed to determine the associations among disease-specific QOL impairments and the severity of anxiety and depression before and after surgery in ENS patients. Methods A total of 68 ENS patients were prospectively recruited and underwent submucosal Medpor implantation. QOL impairments and the severity of anxiety and depression were evaluated using the Sinonasal Outcome Test-25 (SNOT-25), Beck Depression Inventory-II (BDI-II), and Beck Anxiety Inventory (BAI) 1 day before and 6 months after surgery. Results The BDI-II and BAI scores were significantly associated with the total score and ear/facial symptoms, psychological dysfunction, sleep dysfunction, and empty nose symptoms domains of the SNOT-25. Surgery improved disease-specific and psychological symptoms. Post-operative changes in the BDI-II score were correlated with changes in the total score and sleep dysfunction and empty nose symptoms domains of the SNOT-25. A SNOT-25 total score of greater than 60, sleep dysfunction domain score of greater than 18, and empty nose symptoms domain score of greater than 14 were good predictors of moderate-to-severe depression. Conclusions ENS symptoms are associated with psychological burden and could be good predictors of moderate-to-severe depression. Targeted symptom improvement could reduce the psychological burden.

Background No diagnostic criteria have been available for nonallergic rhinitis (NAR) to this point in time. Nonspecific nasal hyperresponsiveness (NHR), which could be efficiently assessed by cold dry air (CDA) provocation, is an essential feature of NAR. Thus, this study's purpose was to assess the diagnostic value of CDA provocation in discriminating patients with NAR from healthy individuals. Methods CDA provocation was performed among 13 healthy volunteers and 15 NAR patients. Nasal symptom scores, total nasal volume (TNV), total nasal resistance (TNR) and minimal cross-sectional area (MCA) were checked before and after the provocation. Non-paramedic tests and receiver operating characteristic (ROC) curves were used in data evaluation. Results Subjects in the NAR group showed significantly larger changes after CDA provocation in total nasal symptom score (TNSS) and nasal congestion score compared with healthy volunteers, while the change for rhinorrhea score was comparable. Similarly, significant differences in the change of MCA and TNV were witnessed between both groups. We built a predictive model for NAR, Y = minus 3.285 plus 2.520 times the difference of TNR (%) plus 1.027 times the difference of TNSS minus 6.542 times the difference of TNV (%), whose area under curve was 0.93. According to the Youden index, the criterion was set to be Y greater than -0.52, when its sensitivity and specificity were 93.3% and 84.6%, respectively. Conclusions With superior patient-friendliness, safety and efficacy, we successfully performed the first NAR predictive model in the Chinese population, based on a short protocol of CDA provocation, by means of both subjective scores and objective tests (acoustic rhinometry and rhinomanometry).

Introduction: Patients suffering from nasal obstruction due to nasal valve compromise may benefit from a nasal dilator. Several devices for widening of the external/internal nasal valve region can be applied endonasally (Airmax, Nasanita, Nozovent) or externally (Breathe Right). Materials and methods: 100 patients suffering from nasal obstruction due to external or internal nasal valve compromise were involved in this study. All patients were evaluated for nasal obstruction with visual analogue scores (VAS) and peak nasal inspiratory flow (PNIF) measurements before and after the application of 4 nasal dilators. They were offered to choose 2 out of 4 for a trial period of 1 month. Subsequently, patients were reassessed and asked about their willingness to continue using the dilators, as well as the reasons for discontinuation. Results: There was a significant decrease of VAS scores and improvement in PNIF with the dilators in situ compared to baseline. After 4 weeks, 67% of patients were willing to continue using at least one of the chosen dilators. The reasons for discontinuation were local irritation, inappropriate fit, preference for a permanent solution like surgery, and no relief of symptoms. Conclusion: Nasal dilators represent a valuable option in the therapeutic approach of nasal valve compromise, with endonasal dilators achieving higher increase in PNIF in comparison with external nasal dilators.

Background The aim of the present study was to explore the relationship between excessive daytime sleepiness (EDS), Peak Nasal Inspiratory Flow (PNIF), and patient reported symptoms from the nose. Methology Six hundred and fifty one consecutive patients referred to a hospital on suspicion of sleep related breathing disorder (SRBD) were included in the study. Daytime sleepiness was assessed by Epworth Sleepiness Scale (EpSS). Nasal airflow was measured with Peak Nasal Inspiratory Flow (PNIF). Symptoms of sino-nasal dysfunction and diseases were graded on Visual Analogue Scales (VAS). Results EpSS score was not correlated with nasal flow as measured by PNIF or nasal obstruction - VAS scores. There were significant associations between daytime sleepiness and patient-reported VAS-scores on nasal discharge, headache, coughing, general health and to some extent sneezing when age, gender, BMI and reported co-morbidity levels were adjusted for. Conclusion A clinical implication of this is that patients with EDS may be evaluated and treated for sino-nasal disease, while medical and surgical measures to open the nose per se may not be effective therapeutic options. A scientific implication is that the relationship between SRBD and sino-nasal disease should be further investigated.

Background Inferior turbinate procedures are applied to relieve medically refractory nasal obstruction. However, the nature of congestion differs between allergic(AR) and non-allergic rhinitis(NAR). This study compares surgical outcomes between AR and NAR patients. Methodology A case-control study of patients undergoing turbinate with or without septoplasty surgery for nasal obstruction was performed. Patient reported outcomes were: nasal obstruction, global nasal function(GNF), and sino-nasal outcome test(SNOT-22) with rhinitis, facial symptom, sleep and psychological sub-scores. Nasal peak inspiratory flow(NPIF) assessed nasal airflow. Measurements were obtained preoperatively and 3 months postoperatively. Results 190 patients were assessed. AR had worse obstruction and worse GNF. All outcomes improved post-surgery; nasal obstruction, GNF, SNOT-22, rhinitis-symptoms, facial-symptoms, sleep-function, psychological-function and NPIF. GNF improvement was greater in AR. NPIF improvement was similar between groups. Conclusions Both AR and NAR patients gained benefit from surgery to relieve nasal obstruction. AR patients demonstrate greater improvement in GNF score but allergy management may contribute to this.

BACKGROUND: The validity of many measurement instruments frequently used in rhinology is unknown. This study describes clinimetric properties of well-known subjective and objective outcomes, i.e., the Glasgow Health Status Inventory, Glasgow Benefit Inventory, Peak Nasal Inspiratory Flow, and 4-Phase Rhinomanometry, in adults with nasal obstruction. METHODOLOGY: Construct validity and responsiveness were determined in 111 patients. Inter-rater and intra-rater reliability were analysed in 30 patients. We assessed content validity by interviewing patients and ENT-surgeons; construct validity by comparing hypothesised associations to calculated correlations between the outcomes; inter-rater reliability by having two researchers perform objective measurements in the same patients; intra-rater reliability by having one rater administer all instruments twice within a two-week interval; and responsiveness by comparing patients scores at baseline and three months after septoplasty or non-surgical management. RESULTS: All instruments demonstrated adequate content validity, inter-, and intra-rater reliability. Analyses of construct validity yielded low Pearsons correlations between the subjective and objective outcomes. Comparing septoplasty to non-surgical management, only the Glasgow Health Status Inventory scores were different between the two groups (mean difference 10.4, 95% CI 6.9 - 13.9). CONCLUSION: All measurement instruments scored appropriately on content validity and reliability, but only the subjective GHSI scored well on responsiveness.

Nasal obstruction is one of the most frequent and bothersome symptoms in rhinosinal disease. Although we are able to measure nasal airflow, the correlation between the feeling of nasal obstruction and objective measurements has been shown to be average at most. A significant proportion of the European population has a more or less deviated nasal septum and deviated septa have received a lot of attention from otorhinolaryngologists. In sharp contrast is the amount of hard evidence concerning septoplasty with or without turbinate surgery.

Background: We aimed to compare the prevalence and risk factors of chronic rhinosinusitis (CRS) using two different diagnostic criteria with the same statistical data from the Korean National Health and Nutrition Examination Survey in 2009. Methods: Symptom-based CRS was defined as CRS diagnosed by questionnaires related to nasal symptoms. Endoscopy-based CRS was defined based on endoscopic findings and nasal symptoms of symptom-based CRS. Results: The overall prevalence of CRS based on the different diagnostic criteria was as follows: symptom-based CRS was 10.78% (797 of 7,394) and endoscopy-based CRS was 1.20% (88 of 7,343). Comparing symptom-based CRS to endoscopy-based CRS showed slight agreement (kappa = 0.183 (0.150-0.216, 95% confidence interval)). Allergic rhinitis was identified as a common risk factor for CRS based on the two diagnostic criteria. Conclusions: The prevalence and risk factors of CRS were quite different from each other according to the different criteria, even in the same population. Therefore, it would be important to consider what specific diagnostic criteria have been adopted in the studies comparing the prevalence of CRS.

Background: Chronic rhinosinusitis (CRS) is a disease with increasing incidence, characterized by persistent symptoms and negative impact on patient`s quality of life. Nasal inspiratory peak flow (NIPF) and acoustic rhinometry (AR) were studied and compared as assessment tools for CRS with or without nasal polyps (NP), as well as, in follow up monitoring of conservative medical treatment. Objectives: Seventy-eight patients were prospectively studied. Objective assessment included NIPF and AR at baseline and at 4 and 8 weeks after onset medical treatment. Measurements were studied in correlation with Sinonasal Outcome Test-22 (SNOT-22) questionnaire, Visual Analogue Scale (VAS) and endoscopic appearance score (EAS). Results: Both NIPF and AR improved significantly, after medical treatment. NIPF score reflected CRS symptoms` improvement according to SNOT-22 total score at the end of treatment protocol, showing moderate to strong correlation with nasal obstruction VAS grading during the treatment period. AR measures were associated with EAS in all sets of examinations and correlated moderately with VAS scoring at 8 weeks. Conclusion: NIPF and AR were proven to be promising methods for objective evaluation and monitoring of nasal obstruction based on different aspects of nasal physiology in patients with CRS.

Background: Early oral contraceptive pills (OCP) had higher estrogen levels and have been thought to cause nasal obstruction in about 40% of women users. A recent small study conducted on women taking OCP showed no significant effects on nasal patency. The aim of the present study was to analyse in a large number of volunteers if Peak Nasal Inspiratory Flow (PNIF) values could be influenced by modern OCP. Methodology: PNIF was measured in 257 women (from 14 to 51 years old), divided into two groups: the study group composed of 109 healthy women taking modern OCP; the control group composed of 148 healthy women who did not take OCP. 9 women in the study group were excluded because of allergic disease, 248 females were finally considered. Data were statistically analysed and figures/tables were produced to see the effect of OCP on PNIF. Results: The present study could not show any effect of OCP on nasal function. Moreover, while height influenced PNIF in both groups, age was not statistically significant. Conclusion: From the present study, it seems that OCP could have no effects on nasal airflow, confirming that modern OCP with lower estrogen doses should not affect nasal mucosa or nasal patency.

Objectives: We prospectively evaluated and compared the safety, subjective and objective efficacy of the coblation and microde- brider for inferior turbinate reduction. Methods: We designed a prospective randomized trial recruiting 70 patients with symptomatic enlarged inferior turbinates. Forty had coblation and 30 had microdebrider. Objectively, we scored each inferior turbinate size from 1 to 3 pre- and post-operatively. Subjectively, patients completed a visual analogue scale (VAS) evaluating their nasal symptoms, before and after surgery. Results: Both techniques resulted in subjective significant improvement in the VAS for nasal obstruction, and other nasal symptoms. Comparing both groups, coblation showed significantly less pain than the microdebrider. Postoperative bleeding and mucosal tears were less frequent with coblation than with microdebrider but this was nonsignificant. Patient satisfaction significantly improved after both techniques. Conclusion: The submucous coblation is as effective as microdebrider for inferior turbinate reduction. It is easily performed with significantly less postoperative pain than the microdebrider. Both techniques produce significant reduction of the size of the turbinates and associated with a satisfactory improvement of the nasal obstruction, nasal secretion, crust formation, itching, sneezing and dryness. The side effects are minimal with both procedures with significant patient satisfaction postoperatively.

The inability to breathe freely and clearly is a major source of concern to patients and a common symptom in many sinonasal conditions (1). There are of course some semantic differences between terms such as ‘obstruction’, congestion’ and ‘blockage’, which have to be clarified when taking a clinical history as the presence of inflammation may produce the sensation of congestion without actually being associated with mechanical obstruction to airflow (2). Notwthstanding this, nasal obstruction is the commonest complaint in chronic rhinosinusitis with and without nasal polyps (3) and is a major feature of conditions from the common cold and acute bacterial rhinosinusitis to allergic and non-allergic rhinitis, septal deformity or a tumour. Paradoxically, many people, myself included, go through life largely oblivious to a significant septal deflection. It therefore begs the question as to why an individual with a long-standing anatomical variant such as this, suddenly presents with the symptom of nasal blockage and it is important that we do not simply focus on the septum (or turbinate) but rather ask ourselves ‘Why now?’ instead of simply listing the patient for septal surgery.

Background: We aim to validate a clinical scoring system of external nasal valve collapse. External nasal valve collapse is a rare and challenging condition. We attempted to simplify the examination of the external valve, the surgical planning and the outcome measure. To validate our external valve score, we first assessed its reliability (inter-rater agreement and test-retest repeatability). We secondly considered the clinical relevance by using our scoring system in patients undergoing septorhinoplasty for external valve collapse. Methodology: For validation, 16 Rhinologists scored patients separately on two occasions. For the clinical relevance, 26 patients with external valve collapse were scored pre- and post-operatively (responsiveness). The external valve score was correlated to peak nasal inspiratory flow. Results: The devised scoring system was reliable (substantial agreement between 16 surgeons with reproducibility over time). All patients in our prospective series showed significant improvement in their external valve score. The quality of life measured by the SNOT-22 tool showed significant improvement after surgery. Conclusion: External nasal valve collapse can be diagnosed and graded using this simple scoring system in the outpatient clinic. This paper reinforces the pivotal role of septorhinoplasty surgery in nasal airway reconstruction and the ongoing need to quantify success.

Background: Previous rhinomanometry studies have shown significant long-term variability of the nasal airway resistance and questioned the clinical validity of rhinomanometry. Research question: Could treatment with a topical glucocorticoid, budesonide, influence the long-term variability of active anterior rhinomanometry? Methods: Eight healthy volunteers participated in an unblinded controlled trial without, and later with, nasal budesonide once a day for 5 months. Their nasal airway resistance was measured every two weeks with active anterior rhinomanometry before and after decongestion with xylometazoline hydrochloride. In addition, subjective nasal obstruction was evaluated on a Visual Analogue Scale before each measurement. The participants had a year earlier been investigated with rhinomanometry every two weeks during 5 months but without budesonide treatment. We compared the variability of nasal airway resistance during the two periods with and without treatment with topical budesonide. Results: Budesonide significantly reduced mean nasal airway resistance and the standard deviation of the mean after decongestion for 6 of 8 participants. The mean reduction of the nasal airway resistance was 40% for the decongested nasal cavity compared to the period without treatment with nasal budesonide. Subjective nasal obstruction assessed by Visual Analogue Scale was reduced in 3 of the 8 participants. Conclusion: The variability of nasal airway resistance was significantly reduced by treatment with topical budesonide for 6 out of 8 healthy volunteers participating in an unblinded repeated 5 month trial where the participants served as their own controls.

Background: Patients suffering from nasal obstruction due to external nasal valve dysfunction may benefit from either corrective surgery or a conservative approach with a nasal dilator. At present, devices for widening the external nasal valve region can be applied externally or endonasally. It remains unknown to what extent the en dona sal dilator Airmax® objectively improves the nasal flow and can be offered as an alternative for surgery. Methodology: Thirty patients suffering from nasal obstruction due to external nasal valve problems were proposed to use the nasal dilator for 4 weeks as an alternative for corrective surgery. The improvement of nasal flow by the dilator was evaluated by measuring the peak nasal inspiratory flow (PNIF). Then, patients were asked for their willingness to continue to use the nasal dilator or to undergo nasal valve surgery. Results: The endonasal dilator improved the mean PNIF from baseline values with a mean increase of 176.1 o/o. After a 4 week trial period, 19 of 30 patients expressed the intention to continue the use of the nasal dilator. Inappropriate size, local irritation and/or aesthetic nasal complaints were mentioned by the other patients as reasons for discontinuation of using the nasal dilator. Conclusion: The endonasal dilator Airmax® represents a powerful device to improve nasal breathing in the target patients and therefore represents a good alternative for corrective surgery.

Background: Chronic rhinitis with inferior turbinate hypertrophy is the most common cause of chronic nasal obstruction. Pharmacological treatment, mainly consisting of corticosteroids, is largely inadequate and, therefore, in the last few years several surgical techniques have been proposed (emptying, radiofrequency, cryotherapy, etc...). The aim of our work is to demonstrate that surgical removal of the inferior turbinate mucosa with the microdebrider, along with the submucosal chorion, results in a full restoration of mucosal physiological structure and function. Methodology: Thirteen symptomatic adult patients were subjected to bilateral inferior partial turbinoplasty with the microdebrider. All patients underwent endoscopic examination, functional nasal tests and nasal mucosa biopsy before and after surgery. Results: The sensitivity in open airspaces improved after nasal surgery, and the results of functional tests returned to within a normal range. SEM examination confirmed that complete mucosal regeneration was within 4 months. Conclusion: Total removal of the inferior turbinate mucosa with the microdebrider in patients suffering from hypertrophic chronic rhinitis allows the perfect regeneration of physiological respiratory tissue and doesn`t have a negative impact on healing time and offsets any adverse postoperative event.

Background: Not much is known about long-term satisfaction of septoplasty. Our goal was to compare pre- and postoperative acoustic rhinometry measurements with satisfaction 11 years after surgery. Methodology: Acoustic rhinometry measurements were performed preoperatively and 3 months postoperatively. Satisfaction was evaluated with semi-structured interviews by telephone 11 years after surgery. Symptoms were evaluated using the NOSE score. Results: In total, 222 patients were interviewed and eligible to enter the study. Of these, 213 had preoperative acoustic rhinometry and 159 had postoperative acoustic rhinometry. In total, 157 patients had a complete data set. Mean follow-up time was 11.3 years. Patients satisfied with surgery had a bigger improvement in total minimum cross-sectional area before decongestion and total nasal cavity volume after decongestion. NOSE scores were not correlated with acoustic rhinometry measurements. Conclusion: Acoustic rhinometry could be a valuable tool for evaluating the results of septoplasty. Satisfaction at 11 years follow-up was associated with 3 months postoperative acoustic rhinometry improvements. Acoustic rhinometry did not show preoperative patient selection potential.

Aims: Measurement of Peak Nasal Inspiratory Flow (PNIF) is a cheap, simple, easily performed method to assess nasal patency and it is suitable for serial measurements and for home use. The purpose of this study was to establish normative unilateral PNIF data for a healthy adult population and provide charts relating unilateral PNIF normal values with various explanatory variables. Methods and results: Repeated measurements of PNIF and unilateral PNIF were performed in 109 volunteers. Ninety seven of these fulfilled the study criteria and all of them were non-smokers, non-asthmatic, without nose and paranasal sinus problems, with ages ranging from 13 to 80 years. Data were statistically analysed and tables were produced relating unilateral PNIF to height which was the only studied variable that correlated statistically with unilateral PNIF. Conclusions: The measurement of unilateral PNIF, providing the present data are confirmed in a larger series, could be a useful method to study single nostril patency to aid diagnosis of nasal disease, especially when it is necessary to assess the functional effects of unilateral nasal septal deviations or in all cases where there is a suspicion of a unilateral nasal occlusion. This pilot study provides initial normative unilateral PNIF data.

Background: Not much is known about long-term satisfaction of septoplasty. The goal of this study was to assess disease specific quality of life outcomes as well as satisfaction at more than 10 years follow-up after septoplasty. Methodology/principal: The study was conducted as a retrospective questionnaire study (based on the NOSE scale) in which a questionnaire was sent to every patient and followed up by a telephone interview conducted in a tertiary otorhinolaryngologic clinic. Results: 238 out of 369 patients who underwent septoplasty accepted to participate of which 222 were eligible. We found a significant reduction in NOSE score from 56.9 before surgery to 31.9 at follow-up. 68.0% experienced improved nasal breathing and 55.9% were satisfied with the overall outcome. Predictive analysis showed that only severity of symptoms before surgery was predictive of all final outcome parameters. Conclusions: Long-term outcome of septoplasty appears to be in line with shorter follow-up. Surprisingly a sizable difference was noted between rate of satisfaction and improvement in nasal breathing. It is important that the surgeon and patient have the same expectations to septoplasty as to avoid any inappropriate disappointment, which is more likely to occur if symptoms are not severe.

PROBLEM: There is no consensus regarding the best approach to select patients for septoplasty. Patient dissatisfaction after septoplasty implies that clinical examination alone is inadequate to detect a clinically relevant nasal septal deviation (NSD). Objective testing provides an in-depth analysis of nasal obstruction and its underlying anatomic causes but it is effort consuming, requires training and it is not widely available. AIM: We studied the role of bilateral simultaneous nasal spirometry (BSNS) in the preoperative selection of patients for septoplasty. PATIENTS, SUBJECTS AND METHODS: Thirty patients with nasal obstruction and NSD were assessed by subjective measures and BSNS before and after septoplasty. The decongested nasal partitioning ratio (NPR) was used as a measure of the degree of NSD. Thirty healthy controls were recruited for providing a normal range of NPR values. RESULTS: All patients were subjectively improved after septoplasty but only those with NPR out of the normal limits had a significant reduction of NPR. Patients with unilateral symptoms and NPR beyond normal limits were also able to identify the more obstructed side preoperatively. For this group of patients, physicians were able to identify the convex side of NSD preoperatively. No correlation between subjective measures of nasal obstruction or airflow asymmetry and NPR was observed. CONCLUSION: BSNS is a rapid, easily interpretable, noninvasive technique, which identifies patients with large NSDs who, irrespective of concomitant mucosal factors of nasal obstruction, warrant septoplasty. BSNS is not applicable in cases with a septal perforation or an S type septal deviation, it cannot detect an insufficient nasal valve and it does not substitute rhinomanometry or acoustic rhinometry.

Background: Acoustic rhinometry is widely used for objective evaluation of nasal dimensions. However, there is a lack of agreement on the normative values in children at baseline, and especially after decongestion. The purpose of this study was to determine the reference values for Finnish school children for acoustic rhinometry in non-decongested and decongested noses, and to find out which of the potential predictors (age, sex, body surface area (BSA) and height) would be the most useful one(s). Methodology: The study included 124 children aged between 6.90 and 13.84 years with no permanent nasal symptoms. Results: At baseline, the mean total minimal cross-sectional area (MCA) was 0.752 cm2, and the mean total volume between 0 - 3 cm (VOL) was 4.00 cm3. After decongestion, the total MCA was 0.794 cm2, and the VOL was 4.38 cm3. There was a significant correlation between MCA and age, between VOL and height, and between VOL and BSA at baseline and after decongestion. We found no difference in the values between boys and girls. Conclusions: We conclude that acoustic rhinometry is a suitable objective method to monitor the changes in mucosal swelling and nasal obstruction in children. Age and height or BSA of a child can be suggested as predictive factors.

BACKGROUND: The Nasal Obstruction Symptom Evaluation (NOSE) instrument is a disease-specific questionnaire for assessing the outcome of an intervention in nasal obstruction in trials. This instrument is only available in the English language and cross-culturally valid questionnaires are very important for all research, including nasal obstruction. The aim of the current study was to reproduce the cross-cultural adaptation process for the NOSE questionnaire in the Portuguese language (NOSE-p). METHODOLOGY/PRINCIPAL: Cross-cultural adaptation and validation of the instrument were divided into two stages. Stage 1 involved four bilingual professionals, an expert committee and the author of the original instrument. In Stage 2, the NOSE-p was tested on 33 patients undergoing septoplasty for internal consistency, test-retest reliability, construct validity, discriminant validity, criterion validity, and response sensitivity. RESULTS: The cross-cultural adaptation process was completed and the NOSE-p was demonstrated to be a valid instrument with satisfactory construct validity. It showed an adequate internal consistency reliability and adequate test-retest reliability. It could discriminate between patients with and without nasal obstruction and it has a high response sensitivity to change. CONCLUSIONS: The cross-cultural adaptation and validation process demonstrated to be valid and the NOSE-p proved to be applicable in Brazil.

Introduction Acoustic Rhinometry, Rhinomanometry, Nasal Spirometry and Nasal Peak Inspiratory flow (NPIF) all measure subtly different constructs of nasal function. All have limitations but NPIF is simple and quick to integrate into clinical practice. The minimum clinically important difference (MCID) for an outcome measure is an estimate of the smallest change that is experienced by a patient or group as being significant. Studies, particularly with large samples, may generate results that while statistically significant, have limited clinical effect. Defining MCID allows an assessment of the clinical impact of an intervention. This study defines the MCID for NPIF. Methods Prospective study of patients from a tertiary clinic undergoing open septorhinoplasty. Nasal obstruction scores and NPIF were recorded before and after surgery. Global function and nasal obstruction scores were used to assess subjective change. Statistical based and patient anchored techniques were used to define MCID. Results 51 patients with a mean age 36 +- 13 yrs (75% female) were recruited. All had open rhinoplasty, septal reconstruction, spreader grafts and turbinate reduction. Baseline NPIF was 101 +- 35 L/min. The statistically derived MCID (half standard deviation) was 18 L/min, the patient anchored approaches were 20 L/min and 20-25 L/min. Discussion Although NPIF is effort dependant with the potential for poor test-retest reliability, it is simple, quick and a reliable technique can be quickly learnt. An MCID of 20L/min is recommended when NPIF is used as an outcome tool. Understanding the MCID is critical for assessing the impact of nasal surgery.

Objectives: Rhinomanometry before and after decongestion distinguishes a nasal airway organic stenosis from congestion of nasal mucosa in patients with nasal stuffiness. Together with rhinoscopy and patient history, it is used to decide if nasal surgery would benefit the patient. Rhinomanometry measurements should thus be reliable and reproducible. Materials and methods: We performed repetitive active anterior rhinomanometry in 9 persons during 5 months to test reproducibility of nasal airway resistance (NAR) over time. We also did test-retest measurements in several participants. Xylometazoline hydrochloride was applied in each nasal cavity to minimize effects of mucosal variation and the nasal cavity was examined with rhinoscopy. The participants evaluated subjective nasal stuffiness on a visual analogue scale (VAS). Results: The long term mean coefficient of variation (CV) of NAR over time was 27% for the whole group while the short term CV was 7 - 17% for test-retest within an hour. Mean NAR reduction after decongestion was 33%, but 13% of NAR values were not reduced after decongestion. Participants had difficulties estimating stuffiness on a VAS in 15% of the assessments, but there was no correlation between the VAS estimates and NAR. Conclusion: We found a high NAR variation over a period of five months. This implies low long-term rhinomanometry reproducibility and we suggest future research on standardised decongestion to increase the reproducibility.

BACKGROUND: Exercise is known to decongest the nasal mucosa which results in increased nasal patency. In a recent study it was suggested that smoking might influence the effect of exercise on the nasal mucosa. This implies that smoking may cause neurological damage to the normal nasal physiology, which has not previously been shown. The aim of this study was to investigate whether there was a difference in nasal mucosal reaction to exercise between smokers and non-smokers. METHODOLOGY: Forty-two smokers and non-smokers underwent acoustic rhinometry to register nasal geometry before and after cycling on an ergometer cycle. A structured interview was used for questions about smoking habits and airway symptoms. RESULTS: Both smokers and non-smokers had a significant increase in MCA (minimal cross-section area) and total nasal volume after exercise. There was no statistical significant difference between smokers and non-smokers. CONCLUSIONS: Smoking does not seem to affect the normal physiological decongestion of the nasal mucosa after exercise.

To improve results in septal surgery patient selection is the mainstay of a successful outcome. Patient history is the basis as well as clinical examination but both are subjective and must be considered towards a background with a high frequency of septal deviation in the population and a lack of good correlation between function and status. Rhinomanometry and acoustic rhinometry as well as nasal peak inspiratory flow are tests of different nasal parameters as resistance to breathing, nasal dimensions and flow. This article illuminates the use of these more objective tests in selection of patients for septo plasty. Objective tests have in several studies shown to predict postoperative satisfaction while normal values can be a marker for a poor surgical outcome. Pros and cons with objective tests are discussed and the conclusion is: operate when there is a good correlation between the patientA`s status, history and the results of rhinometry!

Background: Chronic rhinosinusitis with nasal polyposis (NP) represents an invalidating disorder that causes mainly nasal blockage and loss of smell. The aim of this study is to investigate correlations between individual subjective and objective parameters of stable NP disease. Methods: 65 NP patients scored their sinonasal symptoms on a visual analogue scale (VAS) and questionnaires (SNOT-22 and SF-36). Peak nasal inspiratory flow (PNIF) measurement, Sniffinatm Sticks (SS) smell test, blood analysis for eosinophilia, total IgE and culture for Staphylococcus aureus (SA) were performed. Results: VAS scores for nasal blockage correlated with the SNOT-22 and SF-36 scores, which was not observed for VAS of other symptoms. VAS scores for nasal blockage correlated well with PNIF values as well as VAS scores for smell dysfunction and SS results (both p

Background Computational fluid dynamics has been adapted to studying nasal aerodynamics. Aim To review current literature on CFD studies, with an emphasis on normal nasal airflow, the impact of sinonasal pathology on airflow, and implications on nasal physiology. The objective is to provide the rhinologists with a greater understanding of nasal airflow and how symptomatology of sinonasal disease may be explained via CFD simulations. Results The nasal valve region redirects inspiratory airstreams over the inferior turbinate in a high turbulent kinetic energy, which is important in heat and moisture exchange. The bulk of airflow occurs in the common meatus with small streams traversing the olfactory groove, increasing during sniffing. Septal deviation and enlarged inferior turbinate causes redistribution of airflow, changes in intranasal pressure and increased turbulence. High velocity airflow and wall shear stress at the septal perforation causes desiccation and mucosal damage. The airflow within an atrophic nasal cavity is predominantly laminar with minimal contact with nasal mucosa. The inferior turbinate is an important organ for air conditioning and preservation during surgery is highlighted. Conclusions Despite some limitations of CFD simulations, this technology has improved understanding of the complex nasal anatomy and the implications of disease and surgery on physiology.

Introduction The aim of this study was to investigate the effects of nasal obstruction with enlargement of inferior turbinates on the aerodynamic flow pattern using Computational Fluid Dynamics (CFD) tools including the effects of turbulence. Methods A high-resolution 3-dimensional model of the nasal cavity was constructed from MRI scans of a healthy human subject using MIMICS 12.0 software. Nasal cavities corresponding to healthy, moderate and severe nasal obstructions were simulated by enlarging the inferior turbinate geometrically. Numerical simulations with turbulent flow models were implemented using FLUENTS for CFD simulations. Results In the healthy nose, the main respiratory air stream occurs mainly in the middle of the airway, accompanied by a diffused pattern of turbulent flow on the surface of the nasal mucosa. The peak value of turbulent flow is found in the functional nasal valve region. However, this aerodynamic flow pattern has partially or completely changed in the models with enlarged inferior turbinate. An inhalation flow rate of 34.8 L/min with a maximum velocity of 5.69 m/s, 7.39 m/s and 11.01 m/s are detected, respectively, in the healthy, moderately and severely obstructed noses. Both total negative pressure and maximum shear stress have increased by more than three and two times, respectively, in severely blocked noses compared to the healthy one. Conclusion Data of this study provide quantitative and quantitative information of the impact of inferior turbinate hypertrophy on the aerodynamic pattern and physiological functions of nasal airflow. By including the model of turbulent airflow, the results of this experimental study will be more meaningful and useful in predicting the aerodynamic effects of surgical correction of inferior turbinate hypertrophy.

Nasal obstruction is commonly due to enlargement of the inferior turbinate. This review discusses the pathophysiology of turbinate enlargement, the indications for, and methods and outcome of turbinate reduction. All techniques are successful but vary in their long-term efficacy, their propensity for complications and the degree to which they may adversely affect nasal function. Newer techniques under local anaesthetic and often endoscopic control offer outpatient treatment with satisfactory outcomes. However selecting a particular technique should take account of the individual patient's features, the surgeon's experience and judgement and informed patient choice.

In this study we explored long term outcomes of patients with nasal stuffiness and high nasal airway resistance (NAR) that did not undergo nasal surgery. The same investigation was repeated on average 8 years after a baseline investigation with an ENT-examination, a rhinomanometric survey and a rhinomanometry. We did follow-up investigations in 44 out of 59 non-operated patients with a pathological NAR on at least one side. At follow-up 2 persons (4%) had no complaints, 14 (32%) had reduced, 22 (50%) unchanged, and 6 (14%) increased complaints of nasal stuffiness. Rhinomanometry showed that NAR values decreased significantly between baseline and follow-up on both wider and narrower sides after decongestion. There was no correlation between subjective nasal complaints and NAR-values. In logistic regression models increasing age and allergy prevalence at baseline were significantly associated with having no, or reduced nasal stuffiness at follow-up. The results show that both NAR and subjective nasal stuffiness decreased with age. Consequently, we suggest that NAR normal values should be age adjusted. Also, a wait and see policy towards nasal stuffiness seems relevant since 36% of our patients had no or reduced nasal stuffiness while their NAR-values were reduced after 8 years.

Hot drinks are a common treatment for common cold and flu but there are no studies reported in the scientific and clinical literature on this mode of treatment. This study investigated the effects of a hot fruit drink on objective and subjective measures of nasal airflow, and on subjective scores for common cold/flu symptoms in 30 subjects suffering from common cold/flu. The results demonstrate that the hot drink had no effect on objective measurement of nasal airflow but it did cause a significant improvement in subjective measures of nasal airflow. The hot drink provided immediate and sustained relief from symptoms of runny nose, cough, sneezing, sore throat, chilliness and tiredness, whereas the same drink at room temperature only provided relief from symptoms of runny nose, cough and sneezing. The effects of the drinks are discussed in terms of a placebo effect and physiological effects on salivation and airway secretions. In conclusion the results support the folklore that a hot tasty drink is a beneficial treatment for relief of most symptoms of common cold and flu.

To assess the correlation between nasal inspiratory peak flow (NIPF) and clinical scoring in patients with allergic rhinitis (AR).A concurrent cohort study was carried out with 52 randomly selected patients aged six to 16 with moderate and severe persistent allergic rhinitis, and followed up for eight weeks. Measurements of NIPF and clinical score for AR were evaluated in a blinded manner. Correlations between NIPF and clinical scoring were obtained from linear regression using the Pearson's correlation coefficient (r). Significance level was p0.05.Moderate but statistically significant correlation between NIPF and clinical scoring was found (r = -0.44; por = 0.001) and nasal obstruction alone (r = -0.438; por = 0.001) were found.Results confirm data from studies conducted with adult patients that found weak correlation between allergic rhinitis symptoms and objective measurements of nasal obstruction as NIPF. NIPF and the clinical scoring are complementary tools to evaluate AR patients.

Allergic rhinitis (AR) is characterized by inflammatory events that lead to the onset of typical nasal symptoms, including itching, sneezing, rhinorrhea and obstruction.The aim of the study was to evaluate the relationship between nasal airflow and severity of nasal symptoms, in a cohort of patients with PER METHODS: 312 patients with PER were prospectively and consecutively evaluated performing clinical evaluation and rhinomanometry.Significant relationship exists between severity of all nasal symptoms and degree of nasal airflow limitation (p0.001).This study provides the first evidence that patients with PER show close relationship between severity of nasal symptoms and nasal airflow impairment.

It is generally accepted that congestion during the nasal provocation is most pronounced at about 15 minutes after allergen application. However, it may reach its peak at a different time. This can cause inaccurate assessment of the nasal challenge. The aim of this study was to evaluate the dynamics of early phase congestion during nasal allergen provocation (NPT) and its reproducibility.Two nasal allergen challenges were performed in 26 allergic rhinitis volunteers. Acoustic Rhinometry measurements were recorded beJbre, and then every 5 minutes/for 30 minutes after the allergen application. The sum of cross-sectional areas at the level of the head of inferior nasal turbinate (CSA-2) of both nasal passages was analyzed.The mean time to the occurrence of maximum congestion was 20 minutes. The maximum congestion differed significantly from that recorded at 10, 15 and 20 minutes. The observed patterns of congestive response were not consistent, with inter- and intra-individual differences regarding the time to maximum congestion. Percentage change in airway dimension recorded at the maximum congestion was found the least variable.Evaluation of the maximum congestion pattern during the NPT gives more accurate data compared to a single measurement of nasal patency.

To describe and evaluate our experience with the surgical technique of nasal valve suspension for treating nasal valve insufficiency.Twenty patients with nasal valve insufficiency underwent nasal valve suspension (a total of 33 sides). The patients were prospectively studied and their nasal patency was rated per side pre- and postoperatively, by subjective self-evaluation on a scale from 1 to 10.Post-operatively 7 sides (21%) were rated as unchanged, on 17 sides (52%) the improvement was from 1 to 3 out of 10, and on 9 sides (27%) 4 or more out of 10. The average post-operative improvement for all sides was 2.3 out of 10. In five patients (25%) complications occurred, such as pain, inflammation and suborbital swelling and three eventually underwent a re-exploration of the surgical area, resulting in a permanent scar in one patient.Although nasal valve suspension may be beneficial for some patients, based on our experience, we would not recommend this technique as first line treatment for nasal valve insufficiency. In this series we found relatively limited improvement in most patients and a far higher complication rate compared with other nasal valve procedures we have had experience with in the past.

This study has as its focus on obesity as a factor of importance for nasal blockage. A random sample of 1.900 adults stratified according to age and gender were recruited from the general population. The study included a structured interview about symptoms of nasal blockage and asthma, and a clinical examination with nasal endoscopy. Smoking habits were evaluated by a questionnaire on current and previous smoking. A response rate of 73% was achieved. There was a statistically significant relationship between subjectively experienced daily nasal blockage and registered heavy overweight, but no relationship was found between nasal blockage and age, gender, diabetes or asthma. The odds ratio (OR) for individuals with excessive obesity to have daily symptoms of nasal blockage was 3.7 [95% CI 1.6-7.6]. In patients with nasal blockage, obesity as a cause should be taken into consideration.

Detailed knowledge of the anatomical variations of the lateral nasal wall is crucial for both the surgeon who is performing endoscopic sinus surgery and the radiologist who is involved in the preoperative work-up. Preoperative recognition of these variations will avoid possible complications during the surgery. In this report, we present a unique anatomical variant of the middle turbinate, a large concha bullosa inside a giant concha bullosa, which has never been reported before. Furthermore, we comment on the differential diagnosis of the variations of the middle turbinate and on the embryology of the nasal turbinates. This report also supplies additional aspects to rhinologists in the scope of middle turbinate pneumatization.

The purpose of this study was to characterize the late phase nasal obstruction that is induced by a nasal histamine challenge in sensitized guinea pigs. The volume of the nasal cavity was measured using an acoustic rhinometer. A nasal histamine challenge to unsensitized animals induced nasal obstruction at 30 minutes after the challenge while a challenge to sensitized animals induced nasal obstruction not only at 30 minutes but also at 4-6 hours. Histamine (measured by high-performance liquid chromatography), cysteinyl leukotriene (enzyme-linked immunosorbent assay (ELISA)), prostaglandin D2 (ELISA), eosinophils and basophilic cells of sensitized guinea pigs were not changed in the late phase after histamine challenge. Administration of pyrilamine, a histamine H1 receptor antagonist, and calcitonin gene-related peptide (CGRP) (8-37), a CGRP-1 receptor antagonist, significantly improved histamine-induced nasal obstruction at 30 minutes and in the late phase, respectively. These results suggest that a nasal histamine challenge induces nasal obstruction not only immediately through the histamine H1 receptors but also in a late phase via CGRP.

Parosmia can be defined as a qualitative odor distortion. Despite the consequences of this condition for quality of life, the scientific literature lacks information about the prevalence of parosmia in the general population, which was the objective of the present study.Random samples of 1,900 adult and 401 teenage inhabitants, stratified for age and gender, were drawn from the municipal population register of Skövde, Sweden. In total, 1,713 individuals (74% of the samples) agreed to participate, of which 1,387 (73%) were adults and 326 (81%) were teenagers. They responded to a question about parosmia by means of either a structured interview (adults) or a questionnaire (teenagers).The overall prevalence of parosmia was 3.9% (4.0% in adults and 3.4% in teenagers), which was stable across gender, but differed somewhat between age groups, with highest prevalence in the age group 20-29 years.The rather high overall prevalence, 3.9%, does indeed suggest that parosmia deserves attention when attempting to better understand olfactory dysfunction in clinical settings and in the general population of both adults and teenagers.